Finding Opportunities for Health-Care System Advancement in the COVID-19 Crisis.

The coronavirus disease 2019 (COVID-19) pandemic forced American medical systems to adapt to high patient loads of respiratory disease. Its disruption of normal routines also brought opportunities for broader reform. The purpose of this article is to describe how the Carl R. Darnall Army Medical Center (CRDAMC), a medium-sized Army hospital, capitalized on opportunities to advance its strategic aims during the pandemic. Specifically, the hospital sequentially adopted virtual video visits, surged on preventative screenings, and made-over its image to appeal to patients seeking urgent care. These campaigns supported COVID-19 efforts and larger strategic goals simultaneously, and they will endure for years to come. Predictably, CRDAMC encountered obstacles in the course of its transformation. These obstacles and their follow-on lessons are provided to assist future medical leaders seeking quantum change in the opportunities made available by health crises.

Emergency Department Adaptations to COVID-19.

BACKGROUND: The COVID-19 pandemic creates unique challenges for healthcare systems. While mass casualty protocols and plans exist for trauma-induced large-scale resource utilization events, contagious infectious disease mass casualty events do not have such rigorous procedures established. COVID-19 forces Emergency Departments (EDs) to simultaneously treat seriously ill patients and evaluate large influxes of 'worried well'-while maintaining both staff and patient safety. METHODS: The objectives of this project are to create an avenue to evaluate large surges of patients while minimizing hospital-acquired infections. After identifying areas for improvement and anticipating potential failures, we devised eight healthcare delivery innovations to address those areas and meet our objectives: (1) Parallel ED Lanes (2) Universal Respiratory Precautions (3) Respiratory Drive Through (RDT) (4) Medical Company (5) Provider Triage (6) ED Quarterback Patient Liaison (EDQB) (7) Virtual Registration (8) Virtual Ward. RESULTS: To date, no staff members have contracted COVID-19 within the ED footprint. Our RDT has seen 16,994 patients and the medical company 1,109. Provider triage has redirected 465 patients, while our EDQB has interacted with 532 and redirected 93 patients for same-day appointments with their Primary Care Manager (PCM). CONCLUSION: The system of care establish at our Military Treatment Facility (MTF) has been effective in maximizing staff and patient safety, while providing a new patient-centered healthcare delivery apparatus.

The Importance of the Study of Cognitive Performance Enhancement for U.S. National Security.

INTRODUCTION: The American military is embarking on the 'Third Offset'-a strategy designed to produce seismic shifts in the future of warfare. Central to the approach is the conjoining of humans, technology, and machines to deliver a decisive advantage on the battlefield. Because technology will spread rapidly and globally, tactical overmatch will occur when American operators possess a competitive edge in cognition. Investigation of cognitive enhancing therapeutics is not widely articulated as an adjunct to the Third Offset, yet failure to study promising agents could represent a strategic vulnerability. Because of its legacy of research into therapeutic agents to enhance human-machine interplay, the aerospace medical community represents a front-running candidate to perform this work. Notably, there are strong signals emanating from gambling, academic, and video-gaming enterprises that already-developed stimulants and other agents provide cognitive benefits. These agents should be studied not only for reasons of national security, but also because cognitive enhancement may be a necessary step in the evolution of humankind. To illustrate these points, this article will assert that: 1) the need to preserve and enhance physical and cognitive health will become more and more important over the next century; 2) aeromedical specialists are in a position to take the lead in the endeavor to enhance cognition; 3) signals of enhancement of the type useful to both military and medical efforts exist aplenty in today's society; and 4) the aeromedical community should approach human enhancement research deliberately but carefully.Malish RG. The importance of the study of cognitive performance enhancement for U.S. national security. Aerosp Med Hum Perform. 2017; 88(8):773-778.

Capitation as an Incentive for Transitioning to Patient-Centered Medical Homes in the United States Army: A Brief Report.

The Army transitioned to a Patient-Centered Medical Home concept for primary care beginning in 2011. In spite of organizational commitment to the paradigm, the transition has not been without pitfalls. This performance improvement project operated under the hypothesis that focusing on the market-based incentives of a capitated system would result in a quantum leap toward the Patient-Centered Medical Home ideal. Utilizing a simple teaching device to repetitively highlight clinic and provider behaviors incentivized in a value-based payment system, a single clinic achieved significant improvements in enrollment, patient satisfaction, and measures associated with prevention while assuming an identity as a "virtual clinic". We recommend that the military consider a similar philosophy in educating clinics across the enterprise.

Returning to duty from temporary disability in the U.S. Army: observational data and commentary for commanders, providers, and soldiers.

Before 2011, Army commanders were unable to achieve complete visibility of soldiers possessing temporary medical limitations. The creation of time-limited definitions and technical categorization of this group, now known as the medically not ready (MNR) population, eventually allowed its quantification. With heightened visibility of the group, leaders in the Fort Stewart community facilitated its management through soldier medical readiness councils. In this commentary, we introduce a project that identified and tracked a cohort of 2,490 MNR soldiers for a 1-year period until they either recovered or entered the medical separation process. We identified that musculoskeletal injuries accounted for a heretofore unrecognized 87.4% majority of the MNR population. Prognosis of the MNR population was generally good. Fifty percent of the population returned to duty within 90 days of illness/injury. Seventy-seven percent returned to duty during the follow-up period. Although low back and knee/leg injuries were the largest contributors to the MNR population, low back issues were more likely to result in medical separation. Traumatic brain injury and post-traumatic stress disorder did not contribute significantly to the MNR population. This article seeks to describe the natural history of the MNR category of temporary disability for commanders, providers, and soldiers alike.

The effectiveness of Soldier Medical Readiness Councils in reducing and shaping the population of soldiers not medically deployable.

The population of Soldiers not medically fit for deployment has created readiness problems for the U.S. Army in recent years. To address this issue, the 3rd Infantry Division created councils of experts to address the size of its medically nondeployable population. Our results demonstrate success in effectively reducing the subpopulation of Soldiers who have been medically nondeployable for long periods of time by enforcing their return to duty or medical retirement. This study also demonstrates that council-based management affects the composition of the medically-not-ready population. Traditional approaches allow a minority subpopulation of Soldiers with poor prognoses to dwell within the nondeployable population for long periods of time (6-18+ months), whereas the healthier majority recovers within the first 6 months. This creates a dynamic in which remaining in the population for longer time periods increases the probability of being medically retired. Our study demonstrates that councils consistently and actively shape the character of the group such that those remaining in the medically-not-ready population for longer periods of time do not have an increased risk of medical retirement. Soldier Medical Readiness Councils have already been adopted by the Army. This article provides evidence to support their efficacy.

Perceptions of frontline providers on the appropriate qualifications for battalion level care in United States Army ground maneuver forces.

OBJECTIVES: The U.S. Army emplaces physician assistants (PAs) in its maneuver battalions. When contingencies arise, clinic-based physicians join them to augment capability. Because both entities operate similarly, the policy permits a comparison of perceptions of optimal skill sets for the battalion medical mission. METHODS: We conducted a survey to discover associations in opinion regarding the best qualifications for battalion care. We asked deployed PAs and physicians to rate themselves and their counterparts in eight domains. We hypothesized that both entities would rate PAs as superior based on their permanent presence at battalion level and their familiarity with the disease and injury patterns of their population. RESULTS: Among 26 respondents, PAs awarded themselves a score of 8.3 +/- 0.3 out of 10 and a score of 6.5 +/- 0.5 to physicians. Physicians awarded PAs a score of 8.4 +/- 0.3 and themselves a score of 8.3 +/- 0.3. CONCLUSION: Participants support the PA as an appropriate capability for battalion care in prolonged combat environments.